<!doctype html>
<html>
<head>
<meta charset="utf-8">
<title>送货地址</title>
    <link href="/jst_website_ext/static/src/css/index.css" rel="stylesheet" type="text/css">
    <link rel="stylesheet" href="/web/static/lib/bootstrap/css/bootstrap.css" type="text/css"/>
    <link rel="stylesheet" href="/website_exchange/static/src/css/bootstrap-datepicker3.min.css"/>
    <script type="text/javascript" src="/web/static/lib/jquery/jquery.js"></script>
    <script type="text/javascript" src="/web/static/lib/jquery.validate/jquery.validate.js"></script>
    <script type="text/javascript" src="/website_exchange/static/src/js/bootstrap-datepicker.min.js"></script>
    <script type="text/javascript" src="/website_exchange/static/src/js/bootstrap-datepicker.zh-CN.min.js"></script>
    <script type="text/javascript" src="/jst_website_ext/static/src/js/jst_website_ext.js"></script>
</head>

<body>
	<div id="heade">
    	<div class="heade">
        	<h3>服务热线：<i>021-55226529</i><a href="/kaquan/index">返回</a></h3>
        </div>
    </div>
    <div class="song">
    	<div class="so">
        	<div class="hd">
            	<ul>
                	<li><a href="#"><i>1</i> 输入卡券密码</a></li>
                    <li class="li2"><a href="#"><i>2</i> 填写送货地址</a></li>
                    <li style="margin-right:0;"><a href="#"><i>3</i> OK,好啦</a></li>
                </ul>
            </div>
            <div class="bd">
                <form action="${form_action}" method="post" role="form" id="form-card-exchange">
                <ul>
                	<li class="clearfix">
                    	<dl class=" clearfix">
                        	<dt>收货人姓名：</dt>
                            <dd><input type="text" name="to_name" class="inp2 form-control required" placeholder="收货人姓名" ></dd>
                        </dl>
                        <dl class="clearfix">
                        	<dt>手机号码：</dt>
                            <dd><input type="text" name="mobile_number" class="form-control required mobile inp2" placeholder="手机号码"></dd>
                        </dl>
                        <dl class="clearfix">
                        	<dt>座机号码：</dt>
                            <dd><input type="text" name="phone_number" class="form-control phone inp2" placeholder="座机号码"></dd>
                        </dl>
                        <dl class="clearfix">
                        	<dt>省：</dt>
                            <dd>
                            	<select id="province" name="province" class="form-control required">
                                    <option value="0">--请选择--</option>
                                    <% for item in provinces %>
                                    <option value="${item['id']}" <% if province==str(item['id']) %>selected="selected"<% endif %>>${item['name']}</option>
                                    <% endfor %>
                                </select>
                            </dd>
                        </dl>
                        <dl class="clearfix">
                        	<dt>市：</dt>
                            <dd>
                                <select id="city" name="city" class="form-control required">
                                    <% for item in cities %>
                                        <option value="${item['id']}" <% if province==str(item['id']) %>selected="selected"<% endif %>>${item['name']}</option>
                                    <% endfor %>
                                </select>
                            </dd>
                        </dl>
                        <dl class="clearfix county-select">
                        	<dt>县区：</dt>
                            <dd>
                                <select id="county" name="county" class="form-control required">
                                    <% for item in counties %>
                                        <option value="${item['id']}" <% if province==str(item['id']) %>selected="selected"<% endif %>>${item['name']}</option>
                                    <% endfor %>
                                </select>
                            </dd>
                        </dl>
                        <dl class="clearfix">
                        	<dt>街道门牌地址：</dt>
                            <dd><input type="text" name="address" placeholder="街道门牌地址" class="form-control required inp2" value="${address}"/></dd>
                        </dl>
                        <dl class="clearfix">
                        	<dt>期望发货时间(第二天起)：</dt>
                            <dd><input id="delivery_date" name="delivery_date" type="text" class="form-control required inp1"
                  start_delivery_date="${start_delivery_date}" end_delivery_date="${end_delivery_date}" value="${delivery_date}" /></dd>
                        </dl>
                        <button name="submit" class="" type="submit" value="exchange">提交</button>
                    </li>
                </ul>
                </form>
            </div>
        </div>
        <p class="pp"><img src="/jst_website_ext/static/src/images/yin.png" width="846" height="32"></p>
        <% include "common/foot.html" %>
    </div>
<!--<script type="text/javascript">jQuery(".ka").slide();</script>-->
</body>
</html>
